I am Forbes' Opinion Editor. I am a Senior Fellow at the Manhattan Institute for Policy Research, and the author of How Medicaid Fails the Poor (Encounter, 2013). In 2012, I served as a health care policy advisor to Mitt Romney. To contact me, click here. To receive a weekly e-mail digest of articles from The Apothecary, sign up here, or you can subscribe to The Apothecary’s RSS feed or my Twitter feed. In addition to my Forbes blog, I write on health care, fiscal matters, finance, and other policy issues for National Review. My work has also appeared in National Affairs, USA Today, The Atlantic, and other publications. I've appeared on television, including on MSNBC, CNBC, HBO, Fox News, and Fox Business. For an archive of my writing prior to February 2011, please visit avikroy.net. Professionally, I'm the founder of Roy Healthcare Research, an investment and policy research firm. In this role, I serve as a paid advisor to health care investors and industry stakeholders. Previously, I worked as an analyst and portfolio manager at J.P. Morgan, Bain Capital, and other firms.

Don Berwick, Martyr for Socialized Medicine

I have a piece up at National Review in which I reflect upon Don Berwick’s controversial tenure as Administrator of the Centers for Medicare and Medicaid Services, the 800-billion-dollar federal agency that dominates the American health-care landscape. Despite White House rhetoric to the contrary, I write, Berwick “wasn’t done in by Republican intransigence. He was done in by presidential cowardice. And therein lies a microcosm of everything that’s been wrong with Obamacare.”

The thing to understand about Don Berwick is that there are really two Don Berwicks. There’s the Don Berwick who, through the Institute for Healthcare Improvement, has focused on apolitical aspects of health delivery reform. Here’s what I wrote about Berwick in April 2010:

First, the good. Berwick is a serious and credible health-care analyst. In his capacities both as a Harvard professor and as founder and CEO of a Cambridge-based think-tank called the Institute for Healthcare Improvement, he has written extensively about health-care policy in all of the leading scholarly journals. His focus, in most of these writings, is on the quality and efficiency of health care: things like avoiding medical errors and unnecessary spending. He was granted an honorary knighthood by Queen Elizabeth for his role in shaping Tony Blair’s (mostly futile) attempts to modernize Britain’s National Health Service.

While he was a big supporter of Obamacare, Sir Donald acknowledges its core failing; in an October lecture, he said, “Health-care reform without attention to the nature and nurture of health care as a system is doomed. It will at best simply feed the beast, pouring precious resources into the overdevelopment of parts and never attending to the whole — that is, care as our patients, their families, and their communities experience it.” Indeed, if you put Berwick in a room with a leading market-oriented health-care analyst, the two would find broad areas of agreement as to where our health-care system fails patients.

“But [those experts] would diverge on the most important questions of all,” I noted: “can and should, the state provide quality health care for all? Can enlightened, public-minded experts effectively manage one-sixth of the U.S. economy?” Here, it is not an exaggeration to say that Berwick’s views are difficult to distinguish from those of the central-planning advocates from old Cold War capitals. “You plan the supply; you aim a bit low,” Berwick once explained. “Historically, you prefer slightly too little of a technology or service to much too much; and then you search for care bottlenecks, and try to relieve them.”

But when Berwick was consulting for Britain’s National Health Service, he was unsurprisingly unsuccessful in centrally calibrating supply and demand. Technocratic health-care whack-a-mole has never worked, and it won’t work now. Most importantly, its main success is in denying British subjects the care they need and want.

There is probably no health-care system in the developed world today that would have delighted the old Soviets more than the British National Health Service. The state owns the insurance system; it owns the hospitals; it owns the clinics. People who try to seek health care outside the system are ruthlessly cut off. The “darkness of private enterprise,” as Berwick memorably described it, is hard to find in the NHS, which is why Berwick admires it so much.

It is, assuredly, comforting for Obamacare’s advocates to declare that Berwick was done in by partisan Republican squabbling. But the fact is that it was the White House that decided not to let Berwick go up to the Senate for a confirmation hearing, a hearing that Republicans were looking forward to. This was a blatant attempt by the President to avoid a proper, public debate between Berwick’s philosophy and that of his Senatorial critics. Perhaps Berwick would have won that debate in the eyes of the public. Thanks to the President, we’ll never know.

There is an important distinction here between the good and the bad of technocracy. Berwick’s career until roughly a decade ago was primarily focused on the need for better information about health and procedures—advancing information-sharing and creating more knowledge for doctors to utilize in pursuing the best outcomes. This is hardly a vile or morally problematic pursuit! Indeed, many on the right support gathering this information and sharing it with doctors with the speed of modern technology.

The problem comes when government steps in, and such information is used as a mandate sledgehammer to enforce central planning and rationing and against innovation and patient-directed care. The technocratic approach goes too far when it presumes that bureaucrats can process this data better than doctors, and that top-down management is the best (and indeed only) way to achieve the desired outcome. We see this fight regularly in the context of the Dartmouth Atlas. http://vlt.tc/sq The danger comes not from this more benign and even laudable pursuit of knowledge and measurement of success, but rather what comes when such immoral arithmetic becomes the top-down enforced mandates of unelected boards and faceless councils. The government overrules the doctor, and the patient is left with bad and worse choices—or a choice that comes too late to save their life. The much maligned Independent Payment Advisory Board by law cannot have a practicing physician serve on it—it is by definition rule by the faceless technocrats.

UPDATE 2: Tevi Troy, who served in the Bush Administration as HHS Deputy Secretary, has some insightful points on the Berwick bungle in response to an editorial from the New York Times. He notes, for example, that Obama could have nominated Berwick during the period in which he had 60 votes in the Senate, but chose not to:

The 18-month delay meant that the Obama administration missed the window in which they had a 60-vote Senate majority that could have confirmed him. Furthermore, the Senate had not even scheduled a hearing on Berwick before the Obama administration recess-appointed him, irking the Democratic chairman of the Finance Committee, Max Baucus. At that time, Berwick had not even completed all of the necessary paperwork for Senate confirmation, and a Senate source has informed me that he still has not completed all of his paperwork. Regardless, once the Obama administration recess-appointed Berwick without a hearing, Berwick’s chances of ever getting confirmed plummeted.

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Adding a free, sales tax funded, government owned and operated system using what President Obama calls “government’s low cost unfair advantages” which have so far been prohibited from being even talked about, could use a VA style civilian healthcare delivery option, to compete for patients with private providers, this real healthcare reform solution that will save lives, money and the U.S. economy.

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Public Option Care will be delivered, from government owned and operated, VA style healthcare facilities for civilians.

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Building new government hospitals all over the US will provide construction jobs quickly and staffing jobs forever.

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See Phillip Longman’s book.

BEST CARE ANYWHERE Why VA Healthcare Is Better Than Yours, second addition.

Hi Avik I have met the man multiple times, before his CMS appt. I have followed his career for a long spell as well.

At meetings, prior to ACA, conservative and liberals alike never bristled nor took repose at his views. Different and thought provoking he was, yes, but never political. I was there, and I wont forget. Reading your piece and others nowadays, reminds of that.

Funny, I feel like appraising Berwick on his NHS and free market remarks are like summing up Micheal Jordan’s career based on his batting average. He was so much more.

Its not idolatry, blind ideological leanings, or dogma which takes me down this path. Its knowing the man had passion and was so very different than leaders of his ilk. Most conservatives versed in healthcare issues who knew him or of him would admit the same.

We disagree. He was virtually all about patient care. Free market vs public made no difference–it was all about outcomes at the end of the day. Take some time and study the IHI site. It is instructive.

If you have the time, also read link below. You may disagree with the piece, but it gives you a measure of the man. I could not envision anyone else scribing it, and its a zig in a zagging world:

http://content.healthaffairs.org/content/28/4/w555.abstract

His loss is ours, five-fold unfortunately. His replacement would agree, but that you wont hear in public. :)

I have a lot of respect for the first Berwick I described — the one who has focused on the quality of health care delivery. I also respect, but strongly disagree with, his eloquent support of socialized medicine. I think Presidents deserve broad latitude in their appointments, but it was the President who chose not to put Berwick through the confirmation process. This idea that Republican partisanship is the reason for Berwick’s departure is bunk, especially coming from Democrats who blocked Bush’s CMS nominee for more than two years.

The past is the past. Inchoate democrats are just that, and I am no less a fan of preening dems as I am of GOP’ers.

However, behind closed doors, folks like Grassley et al, knowledgeable on health care, know darn well what this process is all about. Its virtually 100% partisan.

On the merits, they know who Berwick is and what he is capable of; they have worked with him for years; have talked with their aides and know the substance of the man; and know his colleagues and the admiration they have for him.

In another decade, this would not be an issue. This is Hatfield and McCoy, pure and simple.

Would the dems to this to a competent GOP appointment espousing the beauty of the free market. Probably.

Again, its all partisan, so yes, in 2011 this is GOP payback, nothing more, and I really have an issue with any other root cause. If Romney gets elected, I expect the same nonsense from the other side. I read the tea leaves fairly, and IMHO, correctly.

Again, Brad, you’re ignoring the fact that Obama never sent Berwick up for a hearing. Stipulating all of your views are true, there’s no reason why a great performance from Berwick would have convinced some of the centrist Republicans to support Berwick. We’ll never know.